Underutilization of partial nephrectomy for localized renal cell carcinoma in the U.S.
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In the past, the gold standard for the treatment of localized renal tumors has been radical nephrectomy. Over time however, experience with nephron sparing surgery and, now, laparoscopic approaches have demonstrated oncologic equipoise and may provide for an improved quality of life for patients as compared to those undergoing radical nephrectomy for localized renal masses.
The incidence of localized small renal tumors is increasing (3.8-5.6% annually) and one would predict that the incidence of nephron sparing approaches would increase in concert. Though more technically demanding than radical nephrectomy, nephron sparing offers the intuitive benefit of maximizing residual functioning renal tissue, while maintaining cancer control. A recent evaluation of the SEER database revealed that in 2001, 58% of patients with tumors < 2cm, and 80% of patients with tumors 2-4 cm were managed with radical nephrectomy. This study by Hollenbeck and colleagues suggests that while the use of nephron sparing approaches in the management of small renal masses has increased, it remains underutilized and very much regionalized to urban, teaching, high volume centers in the United States.
The authors used the Nationwide Inpatient Sample database to identify patients undergoing partial or radical nephrectomy in the United States during the period 1988-2002. The authors identified 66,621 patients who underwent either partial or radical nephrectomy during the study period, 7.5% of whom underwent partial nephrectomy. The authors noted that the frequency of partial nephrectomy increased during the study period from 3.7% in 1988 to 12.3% in 2002 (p< 0.001). Moreover the utilization rates for partial nephrectomy increased during the study period from 0.21/100,000 population in 1988 to 1.6/100,000 population in 2002 (p< 0.001). However, the authors noted that the utilization rates of radical nephrectomy also increased during the study period from 7.3/100,000 population in 1988 to 9.8/100,000 population in 2002 (p< 0.0001). Examining odds ratios (OR), patients were more likely to undergo partial nephrectomy at urban (OR 1.1), teaching (OR 1.3), high nephrectomy volume (defined as ??28 nephrectomies/year) (OR 2.5) centers. Utilization of partial nephrectomy at such centers ranged from 33-52%.
This study further demonstrates the regionalization of specialized, technically demanding surgical procedures such as partial nephrectomy to major tertiary care teaching centers. It is alarming that despite the acceptance of partial nephrectomy as an oncologically viable procedure in anatomically receptive tumors, more than half of all tumors < 2cm and 80% of tumors 2 ?C 4cm in diameter are still managed with radical nephrectomy. The contribution of laparoscopic radical nephrectomy as an alternative to open partial nephrectomy has yet to be quantified and may further the underutilization of nephron sparing approaches.
By Christopher G. Wood, MD
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